Records detail troubling history of deaths, alleged abuse at group homes

A company with a state contract worth about $20 million to look after the well-being of some of South Carolina’s most vulnerable adults has a troubling record of resident deaths, staff arrests, lawsuits and allegations of abuse, neglect and exploitation, according to documents, interviews and recordings obtained during a seven-month investigation by The Greenville News.

A troubling history of deaths

A seven-month investigation shows a troubled history of alleged abuse, neglect

Michelle McCarroll recalled the Monday night in 2012 her mother dialed the number of the group home where McCarroll’s 25-year-old brother had been living for about six years on a quiet cul-de-sac in Mauldin.

It was 7 p.m., she said, and time for their nightly ritual watching Family Feud together while talking on the phone.

Roderick Carlton Grove, filling in for another worker at the home where Jamie Rosemond and two other men were living, answered Cynthia Rosemond’s call, McCarroll said. Grove explained that Jamie had lost his phone privileges and was in his room asleep. When she called back 15 minutes later hoping someone else would put her son on the phone, McCarroll said Grove picked up and gave her mother the same response.

What she didn't know was that her son was lying on a busy two-lane road about a half mile away. Jamie, diagnosed with autism and schizophrenia, was struck by two motorists on Ashmore Bridge Road about 6:25 p.m. and died at the scene, records show.

Documents obtained by The Greenville News show that the company for which Grove worked, South Carolina Mentor, knew Rosemond had a history of wandering from the home on Flanders Court, and staff were under orders to check on him every 15 minutes.

On two occasions after the time when Rosemond was struck by vehicles – at 6:30 p.m. and again at 6:45 p.m. – Mentor staff recorded in the log that Rosemond was safely in his room, according to the report of the criminal investigation that followed.

Mauldin police charged Grove with neglect of a vulnerable adult resulting in death that night, according to court records. The Greenville County Solicitor’s Office elected not to go forward with the case due to what they said was a lack of evidence. Without admitting liability, the company settled a wrongful death lawsuit filed by Cynthia Rosemond for $750,000, court records show.

A seven-month investigation by The News has found that Rosemond's case is not an isolated one.

Troubling record

Documents, interviews and recordings obtained by The News reveal that Mentor, the company with a state contract of about $20 million to look after the well-being of some of the state's most vulnerable adults, has a troubling record of resident deaths, staff arrests, lawsuits and allegations of abuse and neglect.

Between July 1, 2011, and the end of May 2016, 10 residents of Mentor-run homes have died, according to the S.C. Department of Disabilities and Special Needs. The agency responsible for overseeing Mentor said it was banned by privacy laws from identifying the individuals or providing details of their deaths.

The agency said that one of the deaths was classified by the agency as a substantiated case of abuse or neglect. DDSN defines substantiated cases as those in which an arrest is made by a law enforcement agency or, in some cases, an investigation by the state Department of Social Services determines the allegation was founded, said DDSN spokeswoman Lois Park Mole.

One day after The News began raising questions with DDSN about Mentor and the agency's oversight of the company, DDSN froze new client referrals to Mentor homes in mid-March and put on hold any plans the company might have to add new homes. Mole said that no other community training home providers were under similar freezes.

In late May, S.C. Inspector General Patrick Maley confirmed his office had begun conducting a formal audit in connection with Mentor. Maley declined further comment when contacted by The News.

According to a May 24 email to the director of DDSN obtained by The News, the inspector general is seeking, among other things, to determine whether the agency is adequately monitoring allegations of abuse and neglect at Mentor facilities, and if those allegations might be underreported.

South Carolina Mentor Director Stan Butkus, who resigned as director of DDSN in February 2009 following a critical audit of the agency by the S.C. Legislative Audit Council, told The News in a written response the company has a nearly two-decade “track record of success” caring for people with intellectual or developmental disabilities in the state.

“For more than 15 years, South Carolina Mentor has been proud to deliver quality-of-life enhancing services to hundreds of residents in the Palmetto State living with intellectual and developmental disabilities and other complex conditions,” said Butkus, who became director of South Carolina Mentor in September 2013.

“With our support, these individuals have the opportunity to live in community-based settings where they participate in the everyday rhythms of community life, often close to family and friends,” he said.

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Michelle McCarroll talks about her brother, Jamie Rosemond, who died while living in a Mentor group home.
Lauren Petracca

Three deaths

Bringing Jamie Rosemond closer led his family to move him to the Mentor home in Mauldin from the Whitten Center in Clinton run by DDSN, said Michelle McCarroll.

In addition to wandering away from the Mauldin home at least twice prior to his death on Dec. 17, 2012, Mauldin police investigated an incident of alleged abuse in which Rosemond received 14 stitches to three places on his head in May 2010, records show. A Mentor worker told police Rosemond grabbed her after demanding his medication and fell on top of her, hitting his head on a kitchen counter, according to the police report. No charges were filed.

Attempts to contact Rosemond were unsuccessful. McCarroll said her mother declined to be interviewed.

But McCarroll said the family has many questions about the care her brother received while living at the Mentor home in Mauldin.

“There were a lot of things that just didn’t sit right with us,” said McCarroll, 40, a preschool aide at the Greenville County School District’s Riley Child Development Center.

Almost exactly one year after Rosemond died, Forrest Carlton, 22, was struck and fatally injured by a hit-and-run driver after he wandered from a Mentor group home in Charleston County on Dec. 8, 2013, records show. Like Rosemond, Carlton had left the home before, and Mentor staff flagged him to be visually checked every 15 minutes, according to court documents.

Police drafted an arrest warrant for a Mentor employee but never got it signed by a judge after Charleston County prosecutors advised that investigators couldn’t say with “100 percent certainty” the employee did not check on Carlton, according to a Sheriff’s Office report.

Without admitting liability, Mentor reached a confidential settlement with the family in their wrongful death lawsuit against the company, court records show. DDSN, also a defendant in the case, paid $75,000 to Carlton’s estate and approximately $32,000 in legal expenses through the state Insurance Reserve Fund, records show.

And on Sept. 5, 2015, at another Mentor home in Charleston County, Charles Noland, 23, choked on a cracker after returning from a hospitalization for pneumonia, according to a coroner's report. Noland, whose family lives in Taylors, was rushed to the hospital where he was declared brain dead seven hours later, records show.

Noland was the subject of two reported incidents of alleged physical abuse in the months prior to his death, including one in which he was hospitalized for his injuries, according to police reports obtained by The News under the S.C. Freedom of Information Act. No charges were filed in either case.

At the DDSN Commission meeting in March, former commissioner Deborah McPherson of Columbia questioned whether Mentor staff should have given crackers to Noland following his hospitalization for pneumonia.

Seven months after his death, the Charleston County Coroner's Office ruled Noland died of natural causes, according to its report obtained by The News through the state Freedom of Information Act. The report did not list the choking incident as a contributing factor.

The State Law Enforcement Division says it closed its investigation into Noland’s death but will not release its report due to a state law that keeps secret the records of SLED's Vulnerable Adult Investigations Unit.

Unrelated to the three deaths, two former Mentor workers currently face charges in Greenville County dating back to 2014, and an ex-Mentor worker was arrested in March in Charleston County in connection with alleged abuse incidents at group homes operated by the company, according to court records.

Few cases substantiated

DDSN Director Beverly Buscemi said the agency is “concerned about any instances that result in bad outcomes.”

“There are never any excuses for bad outcomes, and the reality is, there have been some bad outcomes,” Buscemi told The News in a March interview at the agency’s Columbia headquarters.

From July 1, 2015, through May, there were 85 abuse, neglect or exploitation allegations at community residential facilities operated by Mentor in the state, agency records show. DDSN substantiated two of those 85 cases, according to the agency. The agency substantiated one of the 103 reports of abuse, neglect or exploitation at Mentor homes during fiscal year 2015, which ended June 30, 2015, records show.

Mole said substantiated criminal cases are investigated by the State Law Enforcement Division or local law enforcement agencies. According to DDSN, the 103 cases in fiscal year 2015 represent a 178 percent increase from the 37 reported in fiscal year 2011, and almost double the 54 and 56 reported in fiscal 2013 and 2014, respectively.

The agency could not readily provide The News with details of those reports. But DDSN records obtained by The News show that Mentor-run homes account for a disproportionate number of reported abuse, neglect and exploitation allegations statewide.

Since fiscal year 2011, the number of reported allegations per 100 individuals served by Mentor has ranged from a low of 14.3 in 2012 to a high of 51.5 in 2015. The statewide rate was 9.7 in 2012 and 9.8 in 2015.

“The high percentage of reported allegations may represent some over-reporting,” Mole said. “However, over-reporting is much better than under-reporting. People frequently assume reporting equals substantiation, and it does not.”

‘Most challenging’ cases

Buscemi, who became the agency’s director in 2009 after Butkus’ departure, said that Mentor “serves some of the most challenging folks in our system.”

“Mentor serves a population that many other providers in our state are not willing to serve,” she said, pointing out the company serves special-needs individuals, including those who have both intellectual disabilities and mental illness. “If Mentor did not serve these individuals, they would be sitting in either jail or hospital ERs or those types of settings,” she said.

Butkus estimated that Mentor serves about 75 percent of individuals designated by the state as “having high management needs,” including those with a “dual diagnosis of intellectual and/or developmental disabilities, as well as psychiatric disorders or related behavioral needs.”

South Carolina Mentor serves roughly 200 clients annually in 74 community training homes the company operates in the state. Of those 74 homes, 16 are Community Training Home I residences where caregivers are residents who provide care to non-related individuals in their own homes, and 58 are Community Training Home II residences where Mentor employees provide care to individuals in homes that are owned or rented by the provider organization, according to the company.

Mentor and DDSN officials declined The News’ request for the addresses of all licensed Mentor homes in South Carolina, citing privacy concerns.

Some employees terminated

The agency also could not provide the total number of Mentor employees terminated in recent years in connection with allegations of abuse, neglect or exploitation. DDSN spokeswoman Mole said a worker “must be terminated immediately” when there is a substantiated abuse, neglect or exploitation case.

Statewide, 284 community residential staff have been terminated at facilities run by all providers between July 1, 2012, and April 2016 for “policy and/or procedural violations or employee misconduct,” according to DDSN. The agency could not say how many of those terminations stemmed from cases involving abuse, neglect or exploitation, nor could it break down the number by service provider.

Butkus said Mentor “thoroughly screens” all prospective employees and requires them to submit to “multiple background checks.” Before beginning work, new workers must complete an 80-hour training program in a variety of areas, including the “rights and responsibilities of individuals served.” After being hired, they participate in annual training sessions that include the topic of “individual rights and due process,” he said.

Starting pay is $9.79 per hour, and the average tenure of Mentor’s direct-care staff is 3.5 years, he said. The starting wage is set by the state, which requires that Mentor employees receive wage increases received by comparable workers employed by state agencies, he said.

The average hourly wage of direct-care Mentor workers is $9.86, he said. “We believe our compensation structure is competitive with our fellow providers,” he said.

Butkus said that “we recognize that the work direct support professionals do is challenging and like so many of the caring professions, generally is not compensated at a rate commensurate with the level or effort of the work – and that this challenge is not unique to South Carolina.”

Buscemi told The News that “pay across the system is low” for workers who care for people with intellectual or developmental disabilities, adding that Mentor “does not stick out as being any lower.”

DDSN pays Mentor based on daily service rates for individuals set by the state, ranging from $67.47 to $138.96 per resident for individuals in Community Training Home I residences, and $189 to $274.35 per individual in Community Training Home II residences, Butkus said.

Contract amounts increasing

Contracts approved by the DDSN Commission for the start of a fiscal year, which begins on July 1, have grown from $13.1 million in fiscal 2012 to nearly $19.9 million this fiscal year. Likewise, the number of approved residents to be served annually has climbed from 166 in fiscal 2012 to 233 for fiscal 2017 despite the current freeze on client referrals and new homes, agency records show.

Some of the increase in annual revenues received by Mentor in recent years stemmed from state-mandated wage increases for direct-care staff, Butkus said. Medicaid funds services for Mentor residents, he said, with about 70 percent of the state’s Medicaid program coming from the federal government and the balance from the state.

State regulations require that Mentor residents contribute a portion of their Supplemental Security Income payments, based on a sliding scale required by DDSN, toward their room-and-board costs, Butkus said. The average annual contribution is about $8,500, he said.

The other factor driving recent payment hikes to Mentor resulted from its acquisition of a “troubled provider,” Butkus said, adding that the state “suggested that we take on these homes and improve the quality of services being delivered.” Butkus didn’t identify the provider.

Commissioner concerns

At the March 17 DDSN Commission meeting, Commissioner Eva Ravenel of Charleston and former commission McPherson raised concerns about Mentor.

“This last month has probably been the saddest for me as a commissioner,” Ravenel said. “I’m just hoping that the Mentor program can improve and not have any more instances like we’ve had in the past couple of months.”

Commission Chairman Bill Danielson announced at the end of that meeting that the commission was going into a closed-door session to “discuss contractual matters regarding South Carolina Mentor.” No formal action was taken after the commissioners emerged from the session.

One week after the March meeting, Buscemi, told The News that Mentor had agreed to “implement a freeze on all new expansions, which would mean no opening of new homes.” It was not clear whether Mentor had plans for new homes. The company has added 13 homes in South Carolina for adults with intellectual or developmental disabilities since Jan. 1, 2013, according to DDSN.

No timetable was set for ending the freeze. “We’re going to give them time for that to play out and evaluate the results of that to determine when, if, to lift set freeze,” Buscemi said.

In addition to the expansion freeze, Buscemi said her agency has implemented a freeze on “all new (client) referrals to Mentor,” saying it wasn’t tied to any particular incidents. DDSN spokeswoman Mole said that action was “mutually agreed upon.”

In April, DDSN Commissioner Vicki Thompson told The News she was “very concerned” about the allegations involving Mentor. Thompson, who also serves as executive director of the Rosa Clark Medical Clinic in Seneca, is a former director of the Oconee County Disabilities and Special Needs Board and was appointed by Gov. Nikki Haley last year to the DDSN Commission.

“I think that it is an agency’s job to say to a contracted provider, ‘You can go this far and no farther. If you go farther than that, then we will put you out of business,’” said Thompson. “And then the agency needs to actually put them out of business if the violations continue.”

“I believe that most of the providers in South Carolina are excellent,” Thompson continued. “But I don’t believe all of them are. And when they’re not doing a good job, there should be real consequences because contracting with providers does not absolve state agencies from responsibility or accountability.”

Despite the freeze on new home expansions and client referrals, the DDSN Commission at its June 16 meeting approved a $19.86 million annual contract for Mentor for the fiscal year that started July 1. The new contract represents about a 13 percent hike over the previous amended contract of $17.5 million.

Under the new contract, Mentor would serve up to 233 residents, though DDSN spokeswoman Mole said Mentor will remain under the $17.5 million contract with service to 206 individuals pending the lifting of the freeze.

"If the freeze is lifted, and if consumers with assigned funding for residential services choose Mentor to provide those services, then the contract will be amended accordingly," Mole said. "There is no date set or predetermined to lift the freeze."

In approving the new contract, the commission rejected a proposal by Thompson to place Mentor under what she described as a "probationary" contract.

"I think that the only way we can control some situations that are out of control is through these contracts," Thompson said at the meeting. "Let them know as a commission that we are serious about these corrections."

Buscemi said the agency has been meeting quarterly with Mentor representatives, including Butkus, to address concerns. “Their licensing and QA (Quality Assurance) scores were on a downward trajectory, and we wanted to work with them to improve them,” she said.

“I wouldn’t say that they (the meetings) were punitive,” she said. “But we don’t do that with every provider.”

Buscemi said reviews by DDSN and Mentor management of incidents, staffing and oversight have led to changes or increases in staffing patterns, increased managerial oversight, and a “pretty thorough review of what we refer to as behavioral management plans.”

“I look at the arrests (of Mentor workers) that have happened as evidence that the process works,” she said, adding that Mentor has “worked with and cooperated with those investigating agencies regarding any of these incidents.”

‘Track record of success’

Butkus did not grant a request by The News for an in-person interview, but he did provide 10 pages of responses to questions through a spokeswoman for Mentor.

In his written responses, Butkus said the three deaths of Mentor residents examined by The News, previous allegations of abuse in connection with two of those three residents, and the arrests of three former Mentor workers in unrelated cases did not collectively indicate a serious problem with the company’s care of residents.

While acknowledging that “neither our organization, nor any of our fellow providers, is perfect,” Butkus said that Mentor has “zero tolerance for abuse and neglect of those we support.” He said the company has taken “important steps to enhance the quality of our services.” Those steps include:

Adding 15 positions “linked directly to program oversight and management,” including an area director position in the Greenville program;

Making “adjustments in our group home management structure” and reducing the number of homes overseen by program coordinators from three to two;

Implementing “new protocols and strategies that help us better recruit, screen and retain staff”;

Strengthening the company’s “unannounced program visit protocol.”

Most of the new oversight and management positions, as well as the “enhanced recruiting, screening and retention protocols,” were added last year, he said.

Asked in April about Mentor’s record and DDSN oversight of the company, a spokeswoman for Gov. Nikki Haley said “the governor’s office has worked with DDSN’s executive director and board members to understand what happened and to ensure, to the extent possible given our limited control of the agency, this never happens again.”

“We’ve learned that improvements are underway at S.C. Mentor, but even isolated incidents of abuse or neglect are completely unacceptable,” said Chaney Adams, a spokeswoman for the governor.

In a written response to The News, Bill Allen, Mentor’s vice president of operations for a group of states including South Carolina, described Butkus as a “proven leader in the field of community-based services for individuals with intellectual and development disabilities.”

“He understands that while no provider will ever achieve perfection, we have an obligation to those we support to strive for it in partnership with DDSN,” Allen said.

Michelle McCarroll cleans off her brother's grave in Resthaven Memorial Gardens on Wednesday, May 4, 2016.

(Photo: LAUREN PETRACCA/Staff)

Jamie Rosemond

Despite a history of leaving the group home, Jamie Rosemond managed to walk away one last time

In 2008 and again in 2012, Jamie Rosemond walked away from the Mauldin group home where he was living, including once when he was found walking along a nearby road, records show.

In December 2012, the 25-year-old diagnosed with autism and schizophrenia, broke out a window in his bedroom at the home on Flanders Court run by a company called South Carolina Mentor, according to court records.

Two days later, Rosemond wandered off for the last time.

He was struck by two motorists and killed while walking about half a mile away along Ashmore Bridge Road around 6:25 p.m. on Dec. 17, 2012, according to police records.

Mauldin police arrested Roderick Carlton Grove, the Mentor staff member on duty that night, and charged him with neglect of a vulnerable adult resulting in death, according to police records. Grove denied wrongdoing, and prosecutors later dismissed the charge for lack of evidence, court documents show.

Grove could not be reached for comment.

Ernie Hamilton of Greenville, his attorney, said Grove was filling in for another worker and didn’t know that an alarm system on the window in Rosemond’s bedroom wasn’t working when Rosemond escaped. “He did not commit any crime,” Hamilton said.

“He was relying on his senses – to his detriment – but he was operating under the assumption that everything was working properly,” Hamilton said.

Grove, who lost his job with Mentor shortly after his arrest, filed suit against his former employer. In it, Grove alleged Rosemond had “intellectual and other developmental disabilities that required regular medication and dependence upon his caregivers,” as well as a “known and recorded history of eloping from the Flanders Court home at which he was a resident.”

Grove alleged in his lawsuit that the home was “understaffed and, because of the broken window and disabled alarm system, was not properly equipped to properly monitor Jamie or to prevent elopement,” court records show.

Rosemond’s sister, Michelle McCarroll of Berea, says she has a lot of questions about the care her brother received from South Carolina Mentor, a private company under contract with the S.C. Department of Disabilities and Special Needs to provide services to people with intellectual or other developmental disabilities.

Her mother, Cynthia Rosemond, settled a wrongful death lawsuit in 2014 against Mentor for $750,000, court records show. Attempts to contact Rosemond were unsuccessful. McCarroll said her mother declined to be interviewed.

“My brother was a human being,” McCarroll, 40, a preschool aide at Greenville County Schools’ Riley Child Development Center, told The Greenville News.

Rosemond was diagnosed with autism when he was 7 or 8, and was in special education classes during his school years, McCarroll said. He also was schizophrenic and diabetic, she said.

Rosemond had a history of “physical aggression, verbal aggression/outbursts, property destruction, AWOL, non-compliance and psychotic behaviors,” according to a copy of the Greenville County Coroner’s report McCarroll provided to The News.

Rosemond lived for several years at the Whitten Center run by DDSN, McCarroll said. He lived at the facility in Clinton at the time he graduated from Clinton High and moved to the Flanders Court home in Mauldin in late 2006 or early 2007, she said.

McCarroll said the Mauldin home run by Mentor was about 15 miles from their mother's house, and she wanted him to be closer.

“He had his quiet days; he had his upbeat days,” McCarroll recalled. “He was a people pleaser, but he was quick to let you know when you offended him. He didn’t like anyone to be mad at him.”

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She said she and her brother “had this unique bond; we were really, really close.”

Besides the incidents in January 2008 and August 2012, Mauldin police investigated another incident at the home in May 2010, according to police records provided to The News under the S.C. Freedom of Information Act. Rosemond told a paramedic that a Mentor staff worker struck him on the head twice with a walking cane and pushed him, causing him to strike his head on a kitchen cabinet, records show.

He was taken to Hillcrest Memorial Hospital where he received 14 stitches to his head – seven to the right portion, four to the left portion and three to the front center, according to a police report.

A Mentor worker told police Rosemond grabbed her after demanding his medication, and that he fell on top of her and hit his head on a corner of the kitchen counter, according to a police report.

A paramedic told police that "according to the injuries of what he observed on Rosemond, it didn't make sense of what was reported to him by the social worker," the report said.

As a matter of routine the State Law Enforcement Division assisted in the investigation, but no charges were filed, records show.

A July 2011 report by Mauldin Detective Christopher Beeco noted that “all potential and existing leads have been exhausted.” Pending new evidence, Beeco wrote, “the case is administratively closed.”

McCarroll told The News her family didn’t learn of her brother’s head injury until they saw him during a scheduled visit a short time later. She said her family later learned from a Mentor staff member that the female employee “no longer works there.”

McCarroll said that on the night her brother died, their mother, Cynthia Rosemond, called the Flanders Court home about 7 p.m. to speak with her son. She planned to watch the television game show “Family Feud” with him while on the phone, McCarroll said.

Grove, the only Mentor staff member on duty that night, told her that Rosemond had lost his phone privileges for unexplained reasons and was in his room asleep, McCarroll said.

In a written response to The News, Stan Butkus, director of South Carolina Mentor, said that as a practice the company does not limit the phone privileges of individuals it serves.

Rosemond’s mother called back about 15 minutes later hoping to get another Mentor worker, but Grove answered the phone again and gave her the same answer, McCarroll said.

She said that based on those conversations, her mother didn’t think anything was wrong when she saw a news report later that night about an unidentified pedestrian who was struck and killed on a nearby road.

Rosemond was killed when he was hit at 6:25 p.m. by two motorists – who were not charged – while walking along Ashmore Bridge Road about a half mile from his group home, according to a police accident report.

In court papers, Grove said Rosemond escaped out his bedroom window but did not trigger an alarm because Rosemond had broken the window two days earlier.

Grove's attorney, Hamilton, told The News that Rosemond didn't escape the day the window was broken but had the opportunity to do so two days later because the window alarm wasn't working. Hamilton said the alarm couldn't be reset because the window hadn't been fixed.

McCarroll speculated that her brother might have become agitated and walked away from the home if he wasn’t fed or hadn’t receive his scheduled medications.

“Toxicology results were negative for all tested substances,” according to the Greenville County Coroner’s report.

Greenville County Coroner Parks Evans told The News that his office typically has a "blanket (test) panel that covers just about everything – aspirin, stuff like that."

"Anything that could cause death, we check for," he said, noting the tested substances include therapeutic drugs.

Just hours after his death, Mauldin police arrested Grove, then 55, on a charge of neglect of a vulnerable adult resulting in death, records show.

Under state law, willful abuse or neglect of a vulnerable adult resulting in death is a felony that carries a maximum 30-year prison sentence. The maximum sentence is 15 years for abuse or neglect cases involving great bodily injury.

“He’s classified as a vulnerable adult,” Mauldin Police Sgt. Ben Ford told Grove during a video-recorded interrogation viewed by The News under the state Freedom of Information Act. “It’s not intentional abuse. It’s neglect. It’s failure to take care of what you had to take care of, and he’s ended up dead.”

Ford, who supervises the detective unit, questioned Grove as to why he didn’t perform visual checks of Rosemond every 15 minutes that evening as Mentor required for Rosemond. Time logs filed by staff indicated Rosemond was in his bedroom at 6:30 p.m. and at 6:45 p.m. – "which is impossible because he was dead in the roadway at that time," according to a report by Ford.

Grove, the only worker on duty that evening, told Ford that after feeding Rosemond and the other two residents and giving them their medications around 5 p.m., Rosemond went to his bedroom and closed the door.

Grove, who told Ford he worked as a full-time state correctional officer, said he could hear Rosemond talking and playing a video game. He said he discovered Rosemond missing at 7 p.m. when he went to give him his scheduled medication, according to Ford's report.

“I didn’t commit no crime,” Grove told Ford, adding later in the interview, “I didn’t mean any harm to the guy. I was always checking on him.”

“I didn’t mean any harm to the guy. I was always checking on him.”

Roderick Carlton Grove, former Mentor staff member

Grove was indicted on the neglect charge in March 2013, but prosecutors dismissed the case in November 2013, court records show.

In a recent interview with The News, 13th Circuit Solicitor Walt Wilkins said he and other prosecutors in his office didn’t believe there was enough evidence to “prove beyond a reasonable doubt a reckless disregard for human life.”

“We all agreed that this did not rise to criminal liability of reckless disregard of Mr. Rosemond’s life,” Wilkins said.

Specifically, Wilkins explained, Grove's statements to investigators that he assumed Rosemond was in his bedroom because he heard video games being played behind the closed bedroom door didn't meet the reckless-disregard standard.

As for dismissing the case after obtaining an indictment, Wilkins said his office routinely pushes cases to the county grand jury for indictment, which is based on a probable-cause standard, to meet a statutory deadline.

Grove’s attorney, Hamilton, told The News that Grove lost his jobs with Mentor and the S.C. Department of Corrections after his arrest but was later reinstated to his prison position.

McCarroll said she was disappointed no criminal conviction resulted from her brother’s death.

“I felt like he (Grove) could have done more,” she said. “If he would have taken that 15 minutes to check, then 15 minutes could have been the difference between him (her brother) being here and him not being here.”

Cynthia Rosemond, who was represented by Charleston attorney Curtis Bostic, filed a wrongful death lawsuit against South Carolina Mentor and Grove, which was settled in June 2014 for $750,000, Greenville County Circuit Court records show. Mentor in court papers denied the allegations.

Grove sued South Carolina Mentor on several grounds, including negligent hiring, retention or supervision of two Mentor workers named as defendants; and "intentional infliction of emotional distress/outrage,” according to court documents.

Grove dropped the suit after the company settled the other case, Hamilton said.

McCarroll said her family paid to have a small memorial sign honoring her brother installed along Ashmore Bridge Road.

At the time of his death, she said, her brother was carrying his wallet containing $7 in cash and a Christmas list of items to be purchased for his mother, McCarroll and her two teenage children.

Forrest Carlton, left, with his father Donald Carlton

(Photo: ABC News 4)

Forrest Carlton

Investigators cite evidence logs modified in Mentor home death

Less than three weeks before Christmas 2013, Forrest Carlton was killed by a hit-and-run driver after wandering from the Charleston County group home where he lived.

A Charleston County Sheriff’s Office report reviewed by The Greenville News said Mentor’s time logs for four residents of the group home on Church Creek Drive had been “pre-filled out” to indicate that Carlton was home at the time of the hit-and-run accident and afterward.

According to the report, investigators determined the logs were modified later to reflect only three of the four residents were present at 3 a.m., 4 a.m., 5 a.m., 5:30 a.m. and 6 a.m. that day.

It wasn't the first time the 22-year-old had left the home run by South Carolina Mentor, according to a lawsuit filed by Carlton’s father.

The lawsuit contended that Mentor allowed him to "elope on numerous occasions, despite knowing that he was an elopement risk," according to court documents.

The Charleston County Sheriff’s Office report said Carlton, who was severely autistic with an IQ "below 70," was “not supposed to have been outside his residence at the time he was fatally struck.”

Carlton, according to the investigation report, was “supposed to have been visually checked by the staff member on duty at the residence every fifteen (15) minutes.”

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In this video, which aired on ABCNews4 in Charleston in 2014, Forrest Carlton's family discusses the case of an autistic man hit, killed by alleged drunk driver.
ABCNews4.com

“All residents are required to be monitored regardless of level of care,” according to Mentor’s “accountability” time logs for Carlton, which were included with the sheriff’s file reviewed by The News.

Except for dining and bathing, according to the Mentor logs, Carlton was to be “out of sight for only 15 min(utes)” when in the home, records show.

Lois Park Mole, spokeswoman for the S.C. Department of Disabilities and Special Needs (DDSN), told The News that the company’s 15-minute check requirement is not a state regulation.

She said group home staff are “responsible for providing appropriate supervision for people receiving services,” and that each person’s “accountability level may be different.”

Stan Butkus, South Carolina Mentor's director, said in a written response to The News that company policy "does not specifically require 15-minute checks, but rather sets guidelines for determining the appropriate and specific level of supervision."

"Supervision requirements are determined based on the needs of each individual in consultation with his or her third-party case manager as part of the development of an individual service plane (ISP)," he said. "In general, a small percentage of the individuals we serve require visual supervision every 15 minutes during waking hours. Of those, it is a minority who also require the same level of supervision overnight."

Clad in his underwear and a shirt, Carlton was struck by a car that fled the scene on Ashley River Road near the home at 3 a.m. on Dec. 8, 2013, according to a police report. He was taken to the Medical University of South Carolina and died later that day of his injuries.

The Sheriff’s Office drafted an arrest warrant for the Mentor worker but didn’t process it after being advised by Charleston County prosecutors that investigators couldn’t say with “100% certainty” that the employee did not “check in or care for the residents in her care to include Forrest Carlton,” according to the sheriff’s report.

The report also noted that a county attorney believed the case “appeared to be ‘civil’ in nature.”

“Do we have the green light to proceed with the charge ‘Neglect to a Vulnerable Adult’ or do we stand down?” Sheriff’s Capt. Donald Martin, then-commander of the Criminal Investigations Division, wrote in an August 2014 email to Chief Deputy John Clark and sheriff's investigators.

“The affidavit is typed and ready for a judge’s signature as soon as we get the word to proceed or not,” Martin wrote.

“Looks like we stand down,” Clark responded. “I am told we don’t have enough to charge.”

In an email response, Watson said Downing "believed that he had probable cause to draft (an arrest warrant) affidavit for review."

"After a review of the case in its entirety by Detective Downing's entire chain of command, which is common in these types of cases, there were concerns about the case lacking sufficient probable cause to be bound over to General Sessions Court, and if bound over, the probability of the State receiving a conviction," Watson said.

Daniel A. Shirley, then 18, of Hollywood, was arrested and pleaded guilty last October in connection with the hit-and-run, police and court records show. Shirley received a 10-year prison sentence, suspended to five years’ probation with credit for time served, according to records.

Carlton’s family did not respond to requests by The News for comment.

Carlton’s father, Donald Carlton, brought a wrongful death lawsuit naming South Carolina Mentor, its parent company and others. Mentor, in court papers, denied the allegations.

Mentor settled the case in December 2014, according to an order by Circuit Judge R. Markley Dennis. The order did not detail terms of the settlement.

“All I can say is that the matter has been resolved,” said Mt. Pleasant attorney Nathan Hughey, who is representing Carlton’s family, when contacted by The News. Hughey said he was bound by a confidentiality agreement.

Butkus declined to comment on the suit. But he issued a prepared statement to The News about Carlton's death.

"Everyone at South Carolina Mentor was devastated by the unexpected death of an individual in our Charleston program in 2013 at the hands of an underage drunk driver,” Butkus said in the statement. “South Carolina Mentor is committed to delivering high-quality services and continuously reviews our programming to ensure that we are meeting the needs of those entrusted to our care."

DDSN, which was named as a defendant in that suit, paid $75,000 in losses and approximately $32,000 in legal expenses through its liability insurer, the state Insurance Reserve Fund, records show.

Charles William Noland with his sister.

(Photo: Provided)

Charles Noland

A long road of abuse allegations and hospitalizations

The death of Charles William Noland last year marked the end of a long road of abuse allegations and hospitalizations for the severely autistic 23-year-old who lived the final years of his life in a Charleston County group home.

Little has been publicly revealed about the circumstances of the life of Noland, whose parents live in Taylors.

Even the cause of his death remained shrouded in mystery for seven months after he died in the intensive care unit of Bon Secours St. Francis Hospital in Charleston, where records show he was rushed after he choked on a snack of crackers and water at the South Carolina Mentor group home where he lived.

About a week before he died, Noland was hospitalized for three days with pneumonia. He died Sept. 5, 2015, of “acute bronchopneumonia,” according to a report by Charleston County Deputy Coroner Dottie Lindsay. The Coroner’s Office released the report on April 8 after two S.C. Freedom of Information Act requests by The Greenville News.

Bronchopneumonia is a type of pneumonia, affecting both lungs and the bronchi. It can be mild or severe, according to online medical information.

Lindsay listed the manner of death as “natural,” though questions remain over whether Noland should have been given the crackers following his recent bout with pneumonia.

Deborah McPherson of Columbia, a former state Department of Disabilities and Special Needs commissioner, publicly raised questions about Noland’s death at a DDSN Commission meeting in March, three weeks before the coroner’s report was released.

“I was told by a reliable source that upon discharge from the hospital after his initial hospitalization for pneumonia, the consumer was fed peanut butter on a cracker by the Mentor staff, which caused choking, and he later died,” McPherson told the commission during a public meeting.

“More than likely, this individual’s death will be ruled as from natural causes, pneumonia,” McPherson said at the meeting. “What were the other contributing factors? Could the death of this 23-year-old been prevented with appropriate care?”

In a prepared statement to The News, Gov. Nikki Haley’s office said it had “a series of meetings and phone calls with DDSN Commissioners, executive management, and law enforcement regarding the death of Charles Noland at the SC Mentor home in Charleston.”

“We have been briefed on efforts by DDSN to ensure the quality of SC Mentor homes generally and specific to the Charleston home where Mr. Noland lived,” the Governor’s Office said.

In a written statement to The News, Stan Butkus, director of South Carolina Mentor, said Noland’s “passing was determined to be due to natural causes."

"We are limited in what we can comment on due to privacy and confidentiality," he said.

The State Law Enforcement Division investigated Noland’s death. No charges have come of it. Agency spokesman Thom Berry said the matter is now closed. Berry declined to discuss specifics of SLED’s investigation, citing a state law that keeps secret the records of the Vulnerable Adult Investigations Unit.

Berry said SLED referred three non-fatal reports involving Noland – two of which were for alleged neglect or the “Standard of Care” violation – to the state Long-Term Care Ombudsman Program in 2012, 2013 and 2015. He said two additional reports of alleged physical abuse of Noland in 2015 were referred to the Charleston County Sheriff’s Office. He did not provide details.

Mark Plowden, chief of staff for Lt. Gov. Henry McMaster, who oversees the ombudsman program, told The News he is banned under federal law from publicly discussing specifics on referrals to the program.

A March 2012 ombudsman’s report obtained by The News detailed eight areas of concern involving Noland, who was living then at the Chancellory Lane group home operated by Carolina Autism Supported Living Services (CASLS). Mentor acquired the assets of Carolina Autism in November 2012, according to company records.

One of the complaints said Noland, then a special education student at West Ashley High School, “repeatedly arrives at school with swelling and bruising on his body.” School records showed he had “11 documented and photographed incidents of injuries of an unknown origin this school year alone,” according to the report.

CASLS staff said they were instructed by their supervisors to remove Noland’s clothing from his bedroom and place it in a locked cabinet in a garage “due to him constantly changing clothes,” according to the report by Brandy Paige, an investigator in the Ombudsman’s Office. The staff said other residents would physically attack Noland when he “steals their clothes and wears them,” the report said.

The report concluded that the group home staff “violated Mr. Noland’s right to own and possess personal property,” adding he was “not causing hurt, harm or danger to himself, other consumers or staff by changing clothes multiple times a day.”

Paige in her report listed 10 recommendations, including that CASLS staff “protect and provide a safe living environment for all residents.”

In February 2015, the Charleston County Sheriff’s Office investigated a referral of a complaint from SLED’s Vulnerable Adult Investigations Unit that Noland and another adult resident of the Chancellory Lane group home had been physically abused, according to a sheriff’s report.

No charges were filed in that case. Three Mentor workers said Noland and the other alleged male victim are “self-abusers and have a documented history of inflicting injury on themselves,” the sheriff’s report said.

“Without the aid of security cameras at the facility, no witnesses of the alleged violation(s), and two victims that are non-verbal but also have a history of self-abuse, I am unable to confirm at this time that any criminal act has occurred,” Deputy Timothy McCauley said in the report.

In May of last year – about four months before Noland’s death – the Sheriff’s Office investigated another incident at the Chancellory Lane home in which Noland was hospitalized. Noland was brought to Bon Secours St. Francis Hospital in Charleston with “severe bruising and swelling in the lower torso, groin and scrotal areas,” according to a sheriff’s report.

A hospital case manager told police she believed Noland was “being abused” at the home, the report said.

A sexual assault exam was performed at the hospital, though the report didn’t specify the test results. The report noted that when deputies tried to obtain Noland’s underwear as evidence, a Mentor worker said the garments already had been washed.

No charges were filed in that case. In a recent written response to The News, 9th Circuit Solicitor Scarlett Wilson said the matter is “a question for law enforcement.”

“To my knowledge, this case has not been reviewed by my office,” Wilson said.

Charleston County Coroner Rae Wooten said in an email to The News that her office was “aware of the May 2015 incident” and “considered that incident in our investigation.”

About a week before his death, Noland was admitted to Bon Secours St. Francis Hospital in Charleston with pneumonia and discharged three days later with a scheduled follow-up visit with his primary-care doctor in a week, according to Deputy Coroner Lindsay’s report, citing an interview with his caregiver at the group home.

“According to the caregiver, Mr. Noland seemed to be doing well,” the report said.

On the day of his death, the caregiver said Noland began to choke and cough after being given a snack of crackers and some water at the Chancellory Lane home. He was brought to the Bon Secours St. Francis Hospital emergency room about 11 a.m. after becoming unresponsive and died about 6 p.m. in the intensive care unit “where he was considered brain-dead,” according to the report.

The choking incident was not listed as a contributing factor in the death, and the report made no mention of toxicology results or any prior incidents of alleged physical abuse.

“I spoke with the decedent’s parents who voiced some concerns over what happened,” Lindsay wrote in her report.

Wooten told The News that her office was “unable to demonstrate that the reported choking incident contributed to Mr. Noland’s death,” and that toxicology results show that medications “prescribed for Mr. Noland were present.”

As for the family’s concerns cited in the coroner’s report, Wooten said, “It is not uncommon that families have concerns about deaths that occur when loved ones are in the care of others.” She said she was “not in a position to speak specifically to their concerns.”

As for the seven-month lapse of time in issuing a ruling, Wooten said in a written response to The News that “each investigation is driven not only by the initial facts and findings, but also by any additional findings, facts, etc. that are uncovered during the investigation. The purpose of the investigation is to determine ‘manner,’ and however long that takes is what it takes."

But Hughey, who was interviewed by The News the day the coroner’s report was released, said he was baffled by the coroner’s findings.

“That’s how my experts feel about it – it’s baffling,” Hughey said in April.

“My sense of the care was that it was woefully inadequate, and it certainly was not in concert with the representation made and the assurances they make on their (Mentor’s) website.”

Noland’s father, Doug Noland, declined comment when contacted by The News. He referred questions to Hughey.

In an interview last month with The News, Luis Riquelme, chairman of the American Board of Swallowing and Swallowing Disorders and an associate professor at New York Medical College, said it's possible that Noland's diet following his hospitalization for pneumonia might have allowed crackers, noting other factors could have contributed to his choking.

"Sometimes adults with intellectual disabilities will eat too fast or put too much food in their mouth, so it puts them at risk for choking," he said. "I think we need to educate professionals working with this population."

Said Butkus, “We continue to mourn his loss and again express our deepest sympathies to his family and those who loved him.”

Other allegations have been substantiated

Former workers facing charges in abuse cases

Three former workers at homes operated by South Carolina Mentor are facing criminal charges, including one who worked at the Charleston County home where Charles William Noland lived, court records show.

Noland, a severely autistic 23-year-old whose final years were marked by pain and hospitalizations, choked on a cracker after returning to the home on Chancellory Lane following his hospitalization for pneumonia, according to a coroner's report. Noland, whose family lives in Taylors, was rushed to the hospital where he was declared brain dead later that day, records show.

The coroner later ruled Noland died of natural causes, and no charges were filed in connection with his death on Sept. 5, 2015, records show.

In a case unrelated to Noland’s death, Charleston County Sheriff’s deputies in March arrested former Mentor worker Georgette Leann Williams, 36, of Ridgeville on two counts of abuse of a vulnerable adult involving two victims, court records show. Each charge, a felony, carries a maximum five-year prison sentence.

Arrest warrants allege Williams had been “yelling, intimidating and pushing the supported persons at this facility.”

The alleged incidents occurred between September and December last year. Noland was not involved in either case, records show.

Ninth Circuit Solicitor Scarlett Wilson told The Greenville News in late March that her office had just received Williams’ case and “will not be commenting on this prosecution until it is resolved.” As of last week, the case remained pending, she said.

Efforts to reach Williams were unsuccessful. She did not have an attorney as of her last court hearing, records show.

In Greenville County, ex-Mentor worker Patsy Denise Robinson, 51, of Laurens faces three charges of abuse of a vulnerable adult in connection with the alleged physical abuse of residents at a Bonnie Woods Drive group home between April 2013 and May 2014, according to arrest warrants.

She is accused of hitting two male victims with a belt and “otherwise slapping or striking” them, and spraying a male victim with pepper spray and striking him “about his body,” according to warrants.

Records show that her supervisor at the time, Clarence Willie Callie Dillard, 49, of Clinton was charged with two counts of failing to report the abuse, a misdemeanor charge carrying a maximum one-year prison sentence on each count.

Robinson and Dillard were arrested in August 2014 and later indicted, records show. Thirteenth Circuit Solicitor Walt Wilkins told The News in mid-March that he couldn’t discuss specifics of the cases but said he expected them “to be resolved in the next 60 days.” The cases remained pending last month, he said.

"We looked at the cases," Wilkins said. "I can't corroborate some of the accusations at all."

Neither Dillard nor his public defense lawyer responded to requests for comment.

Greenville attorney Ernie Hamilton, who is representing Robinson, told The News last month that he understood his client was scheduled to apply to participate in a pre-trial intervention program.

Defendants who successfully complete the program get their charges dropped.

Hamilton earlier said Mentor “dismissed” his client after she was charged. He contended the alleged incidents were not reported immediately to authorities by other mandated reporters, as required by state law.

“My client is relying on the fact that she was accused of doing something that should have been reported long before she was arrested,” he said.

Hamilton declined further comment on that case.

Hamilton also represented former Mentor worker Roderick Carlton Grove, who was arrested in connection with the December 2012 death of Jamie Rosemond, who lived at a Mentor home in Mauldin. Greenville County prosecutors later dismissed the case against Grove.

In a written response to The News, Stan Butkus, director of South Carolina Mentor, said Grove, Robinson, Dillard and Williams are no longer employees of the company.

New call for cameras in group homes

​

Two years after a state investigative agency recommended placing security cameras in common areas of group homes serving vulnerable adults, state officials have yet to implement the proposal designed to protect the safety of individuals.

State Rep. Chandra Dillard, D-Greenville, said Monday she plans to introduce or co-sponsor legislation requiring cameras in common areas of group homes after reading an investigative series in The Greenville News detailing the deaths of three young men in group homes in Mauldin and Charleston County during a recent three-year span.

Dillard said she spoke with Michelle McCarroll of Berea, the sister of Jamie Rosemond, a resident of a South Carolina Mentor group home in Mauldin who died in 2012.

“I’m not opposed to having cameras where they need to be with vulnerable populations,” Dillard told The News. “Given the great loss she (McCarroll) and her family has experienced, this is the least we could do.”

Dillard, the community relations director at Furman University first elected to the House in 2008, said she plans to ask legislative staff this week to begin researching regulations for group homes serving individuals with intellectual or other developmental disabilities. The legislative session opens in January.

During its seven-month investigation, The News disclosed a troubling history of recent deaths and allegations of abuse and neglect involving residents with intellectual or developmental disabilities living in group homes operated by South Carolina Mentor, a company under oversight of the S.C. Department of Disabilities and Special Needs.

The News reported its findings online and in a three-part series that began publishing on Sunday.

McCarroll told The News she believes state law needs to be changed to require cameras in common areas of group homes, and to ensure there are working alarms on doors and windows at those homes.

Her 25-year-old brother, diagnosed with autism and schizophrenia, was struck and killed by two motorists after wandering from his Mentor group home in Mauldin in December 2012. Police charged a former Mentor worker in connection with his death, though prosecutors later dismissed the case.

McCarroll, a preschool aide at Greenville County Schools’ Riley Child Development Center, said she has begun circulating a paper petition locally to support the requirements and also launched an online petition.

“A lot of people don’t believe them (people with intellectual or developmental disabilities),” she said.

A June 2014 audit by the Legislative Audit Council – the investigative arm of the S.C. General Assembly – recommended changing state law to “allow electronic monitoring of common areas of DDSN facilities serving consumers.”

“Video cameras in common areas may help reduce ANE (abuse, neglect and exploitation) and would not be a violation of any individual’s personal space,” the audit concluded. “Cameras could be monitored or video tape could be recorded and reviewed, if an incident was reported or suspected.”

The report, a follow-up to a 2008 audit critical of DDSN, noted that while having video cameras in residents’ rooms “may be a violation of an individual’s personal liberties,” there is no expectation of privacy in common areas, such as dining rooms, day program work rooms or hallways.

In the absence of a change in state law, the LAC recommended that DDSN should require its service providers to “install such monitoring equipment.”

During the regular March DDSN Commission meeting, former commissioner Deborah McPherson of Columbia, whose term wasn’t renewed by Gov. Nikki Haley in 2014, cited Mentor incidents investigated by The News. She called for electronic monitoring in long-term care homes.

“Technology is available to keep individuals safer when they elope,” McPherson told the commission. “Technology can also assist in documenting incidents of abuse and neglect, as well as the prosecution of the abusers. I would support the use of technology, especially in cases of multiple incidents involving non-verbal consumers.”

“Why not have cameras in places that have non-verbal patients?” Commissioner Eva Ravenel of Charleston asked during the meeting. “I don’t say have them in their bedrooms, but definitely have them in the common areas.”

DDSN Director Beverly Buscemi, however, expressed concerns about the proposal.

“There is a significant potential risk as it relates to Medicaid funding and compliance,” she said.

“It’s one thing to do it in a home as a request of one individual family member,” she said. “It is another thing to say, ‘For this category of folks or this type of home or this individual provider across the board,’ because CMS (the federal Centers for Medicare and Medicaid Services) has given that as a very specific example of at least something that would lend to an institutional setting.”

Asked whether he supports video cameras in Mentor homes, Stan Butkus, the company's state director, told The News in a written response: “DDSN promotes a policy of privacy that is generally inconsistent with the use of video recording equipment inside the residences of individuals served. We respect and understand their point of view.”

State Sen. Paul Thurmond, R-Charleston, introduced a bill three years ago that would have allowed residents of nursing homes, or their legal representatives, to have electronic monitoring equipment in their rooms.

Thurmond, who is not seeking re-election this year, told The News he would have supported amending his bill to cover group homes such as the ones operated by South Carolina Mentor, with privacy protections for residents.

“My desire was to discourage abuse and neglect,” he said.

Thurmond’s bill never made it out of committee.

Anna Maria Darwin, a Greenville attorney with Protection & Advocacy for People with Disabilities, a statewide nonprofit legal-rights organization, told The News in a written response that the organization “supports the rights of family members/residents to install cameras at their own cost, with appropriate privacy protections.”

Greenville County Solicitor Walt Wilkins, whose office declined to pursue charges against a former Mentor worker arrested in connection with Jamie Rosemond’s death in 2012, told The News he supports having video cameras in common areas of group homes.

“It would make a huge difference for us if DDSN would require that in their contractual relationships so we could have at least some oversight inside their facilities,” he said. “It would be extremely helpful, especially when you have these vulnerable individuals.”

Mauldin Police Sgt. Ben Ford, who supervises his department’s detective unit and was the lead investigator in the Rosemond case, told The News that video cameras in common areas would assist in abuse and neglect investigations.

Contacted recently by The News, state Sen. John Scott said he believes the broader problem is a lack of accountability by the DDSN Commission and director for what he described as ongoing “safety issues” involving people with intellectual or developmental disabilities under the agency’s oversight.

Scott, D-Richland, introduced a pair of state bills last year that he said would bring greater accountability to DDSN.

The bills, one of which was co-sponsored by Sen. Kevin Bryant, R-Anderson, would have made DDSN a division of the state Department of Health and Human Services, and given the governor the authority to appoint the DDSN director with Senate consent. Currently, the governor, with Senate consent, appoints the seven-member DDSN Commission, which hires a director.

The bills never made it out of committee.

In a written response to Scott’s remarks, Buscemi told The News, “DDSN takes the health, safety and welfare of individuals very seriously, and works with providers to ensure the highest quality of care.”

Some 2008 audit proposals not yet implemented

The S.C. Department of Disabilities and Special Needs said that it has implemented most but not all of the recommendations of a critical 2008 audit issued by the S.C. General Assembly’s investigative arm.

In a written report to The Greenville News, DDSN said that most of the 16 recommendations in the area classified by the S.C. Legislative Audit Council as “health, safety and welfare” were implemented.

Two of the proposals not implemented required legislative changes, according to the agency.

Stan Butkus resigned his position as the DDSN director about two months after the 2008 audit, ending a 13-year tenure as the department’s leader. Since September 2013, he has been the director of South Carolina Mentor, a private company under contract with DDSN to provide services to individuals with intellectual or other developmental disabilities.

Butkus was the director of DDSN at the time of a 2006 S.C. Supreme Court ruling that DDSN owes a common-law duty of care to clients under the care of private providers that contract with DDSN.

Among other things, the December 2008 audit found problems with the agency’s procedures to handle threats to residents’ safety; that it didn’t adequately ensure that workers dismissed for resident safety violations were not rehired elsewhere in the system; and that residents’ funds were often mishandled by local disabilities board staff.

The follow-up LAC audit in June 2014 found that DDSN can “improve its process for protecting DDSN consumers (individuals served by DDSN) in several ways,” and that “certain state laws should be amended to help improve the operations at DDSN.”

The LAC recommended, for example, that DDSN develop “uniform staff training on abuse, neglect and exploitation (ANE) to be completed annually”; and that lawmakers require “pre-hire national fingerprint-based checks for all direct caregivers, regardless of state residency status.”

Asked whether DDSN addressed the LAC’s 2008 findings in the area of health, safety and welfare, agency spokeswoman Lois Park Mole provided The News with a follow-up agency report on the LAC’s recommendations.

Of 16 recommendations in those areas, seven had been implemented at the time of the 2014 audit; four were subsequently implemented; and one remained partially implemented, according to the report. Of the four recommendations not implemented, two required changes in state law, the report said.

One of the proposed legislative changes would have required FBI criminal history checks for all direct caregivers, regardless of how long they lived in South Carolina. Another LAC recommendation not implemented, according to the 2014 audit, would require licensing standards to be amended to mandate the FBI checks for all newly hired caregivers.

DDSN in its follow-up report to The News said it believes the licensing-standard recommendation has been partially implemented because the agency is conducting those checks on all regional center staff, though community providers are not required to do so.

About the company

South Carolina Mentor, founded in 1984 and headquartered in Columbia, is part of a 35-state network of operations, known as “The Mentor Network,” according to company information.

In South Carolina, Mentor has offices in Aiken, Charleston, Greenville, Murrells Inlet and Rock Hill, according to the company.

On its website, the South Carolina company says it has “distinguished itself as a quality provider of services to adults and children with intellectual and developmental disabilities, as well as youth and families with emotional, behavioral and medically complex challenges.”

The company operates 74 homes throughout the state, serving approximately 200 individuals, according to its state director, Stan Butkus, a former director of the S.C. Department of Disabilities and Special Needs, which oversees Mentor and other service providers.

South Carolina Mentor is part of Civitas Solutions Inc., a publicly traded Boston-based company that bills itself in its annual report as the “leading national provider of home- and community-based health and human services to must-serve individuals with intellectual, developmental, physical or behavioral disabilities and other special needs.”

As of Sept. 30, Civitas’ approximately 22,300 full-time equivalent employees and 4800-plus, “independently-contracted host home caregivers” served about 12,400 clients in residential settings and more than 17,000 clients in non-residential settings nationwide, the report said.

Civitas’ total net revenues for fiscal 2015, which ended Sept. 30, were about $1.37 billion, with about 89 percent of its revenue deriving from contracts with state and local governments, according to the report.

Rick Brundrett is an investigative reporter with The Greenville News. Reach him at (864) 478-5904 or rbrundrett@greenvillenews.com. Follow him on Twitter @RickBrundrett.

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Records detail troubling history of deaths, alleged abuse at group homes

A company with a state contract worth about $20 million to look after the well-being of some of South Carolina’s most vulnerable adults has a troubling record of resident deaths, staff arrests, lawsuits and allegations of abuse, neglect and exploitat